Clinical Characteristics and Implications of Bradycardia in COVID-19 Patients Treated with Remdesivir: A Single-Center Retrospective Cohort Study.

BACKGROUND AND OBJECTIVES: Remdesivir is an antiviral drug used to treat coronavirus disease 2019 (COVID-19) with a relatively obscure cardiac effect profile. Previous studies have reported bradycardia associated with remdesivir, but few have examined its clinical characteristics. The objective of this study was to investigate remdesivir associated bradycardia and its associated clinical characteristics and outcomes. METHODS: This is a single-institution retrospective study that investigated bradycardia in 600 patients who received remdesivir for treatment of COVID-19. A total of 375 patients were included in the study after screening for other known causes of bradycardia (atrioventricular [AV] nodal blockers). All patients were analyzed for episodes of bradycardia from when remdesivir was initiated up to 5 days after completion, a time frame based on the drug's putative elimination half-life. Univariate and multivariate statistical tests were conducted to analyze the data. RESULTS: The mean age of the sample was 56.63 ± 13.23 years. Of patients who met inclusion criteria, 49% were found to have bradycardia within 5 days of remdesivir administration. Compared to the cohort without a documented bradycardic episode, patients with bradycardia were significantly more likely to experience inpatient mortality (22% vs 12%, p = 0.01). The patients with bradycardia were found to have marginally higher serum D-dimer levels (5.2 vs 3.4 µg/mL, p = 0.05) and were more likely to undergo endotracheal intubation (28% vs 14%, p = 0.008). Male sex, hyperlipidemia, and bradycardia within 5 days of completing remdesivir were significant predictors of inpatient mortality. No significant differences in length of stay were found. CONCLUSIONS: Bradycardia that occurs during or shortly after remdesivir treatment in COVID-19 patients may be associated with an increased rate of in-hospital mortality. However, COVID-19 and its cardiac complications cannot be excluded as potential contributors of bradycardia in the present study. Future studies are needed to further delineate the cardiac characteristics of COVID-19 and remdesivir.

A single-center retrospective study on the incidence and clinical significance of the electrocardiographic "Triangular QRS-ST-T Waveform" pattern*.

BACKGROUND: The triangular QRS-ST-T waveform is a rare presentation of ST-segment elevation acute myocardial infarction associated with a poor in-hospital prognosis. OBJECTIVE: To evaluate the incidence and clinical implications of the QRS-ST-T waveform pattern. METHODS: Clinical data from non-pregnant adult patients who presented as STEMI activations at a single institution between 2017 and 2021 were reviewed. Patients who met electrocardiographic criteria for triangular QRS-ST-T waveform - a giant wave from the fusion of the QRS complex, the ST-segment, and the T-wave - were included in the study. RESULTS: There were 417 STEMI activations, eight (1.9%) of which fulfilled the criteria for the triangular QRS-ST-T waveform pattern on electrocardiography. Coronary angiography was performed in five of these patients, four of whom demonstrated a significant lesion to the left anterior descending artery. Three patients did not undergo angiography secondary to hemodynamic instability. Seven of the patients in our study experienced cardiogenic shock requiring vasopressor, inotropic, and/or mechanical support. Only two patients survived to discharge; one was successfully bridged to coronary artery bypass grafting via intra-aortic balloon pump, while the other underwent a staged percutaneous coronary intervention. CONCLUSIONS: The triangular QRS-ST-T waveform pattern is a rare ECG finding that may indicate hyper-acute STEMI and is an ominous sign of impending hemodynamic instability. Patients who survived received prompt aggressive therapeutic management.

Blunt Chest Trauma Causing a Displaced Sternal Fracture and ST-elevation Myocardial Infarction: A Case Report.

INTRODUCTION: Blunt chest trauma and motor vehicle collisions are common presentations to the emergency department (ED). Chest pain in a trauma patient can usually and reasonably be attributed to chest wall injury, leading to a potential delay in diagnosis and treatment. CASE REPORT: In this case report, we present a 52-year-old male who was brought to the ED with complaints of chest pain and pressure after a motor vehicle collision. He was subsequently found to have both a displaced sternal fracture and simultaneous acute myocardial infarction with 100% occlusion of the mid left anterior descending artery without dissection requiring stent placement. CONCLUSION: Chest pain after blunt cardiac trauma is a common complaint. While rare, acute myocardial infarction must be considered. Most injuries result as direct trauma to the artery causing either dissection or acute thrombosis resulting in a myocardial infarction as opposed to acute plaque rupture with thrombosis, as seen in this case.

Pericardial effusion as a complication of chronic graft versus host disease.

A 24-year-old man with previous matched unrelated donor allogenic bone marrow transplant for aplastic anaemia and chronic graft versus host disease on steroid taper presented with progressively worsening anasarca. CT revealed large pericardial effusion, while echocardiogram was concerning for early tamponade physiology. He underwent emergent pericardiocentesis with pericardial drain placement. Extensive rheumatological and infectious work-up was unrevealing with patient's presentation attributed to pericardial graft versus host disease. This highlights the need of physicians to be aware of pericardial serositis as a complication of graft versus host disease due to its life-threatening complications, which require immediate intervention.

Twice daily versus once nightly dosing of pregabalin for fibromyalgia: a double-blind randomized clinical trial of efficacy and safety.

OBJECTIVE: To compare the efficacy, discontinuation rates, and safety of once nightly versus twice daily dosing of pregabalin in a community-based trial. METHODS: This multicenter, double-blind, 8-week randomized clinical trial compared the effects of 300-mg daily doses of pregabalin given either twice daily or once nightly for the treatment of fibromyalgia in 177 patients. The primary outcome was the comparison of end point mean pain scores derived from a daily diary. RESULTS: Both twice daily (88 patients randomized) and once nightly (89 patients) pregabalin significantly reduced the average severity of pain experienced by patients (P < 0.001 for both). Treatment-emergent adverse events were reported by significantly more patients in the twice daily group than those in the once nightly group (P = 0.023). There were no significant differences between the groups for the frequencies of individual adverse events (P > 0.05 for all). There was no significant difference in adverse events or efficacy in patients taking both pregabalin and a selective serotonin and norepinephrine reuptake inhibitor or selective serotonin uptake inhibitor. CONCLUSION: While a nightly dosing schedule of pregabalin has been used by clinicians hoping to improve treatment, this study showed no significant difference (either beneficial or detrimental) between either treatment option. While there was a decrease in total patient-reported adverse events in the once nightly arm, the lack of specificity in relation to a particular adverse event suggested no real difference in adverse events.

Identifying individuals at risk for fracture in Guatemala.

INTRODUCTION: The FRAX calculator combines a set of clinical risk factors with country-specific incidence rates to determine the ten-year absolute risk of major osteoporotic fracture. However, regional or country-specific databases from Central American countries are not available. We compared the use of various FRAX databases and the Pluijm algorithm in determining risk of fracture. METHODS: We collected clinical risk factor data needed for the FRAX calculator and Pluijm algorithm of Hispanic women in Guatemala and calculated the FRAX absolute risk measures of major osteoporotic fracture and hip fracture. Subjects were postmenopausal women greater than age 40 with no history of using medication that affect bone. A random sample of 204 women in 34 different regions women in Guatemala City was visited in their homes to complete the surveys. The Pluijm risk score and FRAX risk score using the US Hispanic, Spain, and Mexican databases were calculated. RESULTS: We used the US NOF guidelines for treatment which suggest a treatment threshold for patients with a 10-year hip fracture probability ≥ 3% or a 10-year major osteoporotic fracture risk ≥ 20%. The number of patients meeting the suggested threshold limits for treatment using the Spain and Mexico calculators were identical. There was 100% conformity in threshold limits for both hip and major osteoporotic fracture risk. The mean conformity for any fracture risk between US Hispanic and the other two databases was 97.5%. Conformity was 99.0% based on major osteoporotic fracture and 97.5% based on risk of hip fracture. The Pluijm evaluation shows conformity of 87.2% and 83.3%, respectively, when compared to the US Hispanic and Spain/Mexico FRAX thresholds for risk of fracture. DISCUSSION: Although the different FRAX databases provide variations in the absolute risk of fracture, the overall conformity to treatment thresholds amongst the US Hispanic, Spain, and Mexico databases show the database used would have little effect as to the decision to treat. The Pluijm tool conforms to the FRAX thresholds and can be used as well. It does not matter which country-specific calculator or assessment tool is used, as there are a similar number of patients that would meet the intervention threshold.

Teriparitide update.

Teriparitide (TPD) is a novel anabolic agent that stimulates bone formation. TPD reduces risk of vertebral and nonvertebral fracture. Due to its positive effects on bone formation, many new uses of TPD are being explored. It has been studied and approved for glucocorticoid-induced osteoporosis. Many questions about the use of TPD remain including use of follow-up therapy, combination therapy, sequential therapy, and its potential role in fracture healing and treatment of back pain related to osteoporosis.

Comparison of FRAX Scores of Southern California Females of Mexican Descent Using US Hispanic and Mexico Database.

Introduction. Regional differences for fracture risk of US Hispanics may vary by national origin. In California, where a majority of the Hispanic population is of Mexican descent, it is of interest to compare the FRAX absolute risk using the US Hispanic and Mexico databases. Methods. We collected FRAX risk factor data from 134 women of Mexican descent in southern California. The FRAX risk score was calculated using the US Hispanic and Mexican databases, using the NOF guidelines for osteoporosis to compare the number of patients that would be selected for treatment. Results. The 10-year absolute risk of major osteoporotic fracture among women of Mexican descent using the US Hispanic database was 4.82 ± 5.03 (95% CI 3.97-5.67) compared to 4.86 ± 4.72 (CI 3.98-5.44) using the Mexico database (P = .94). The 10-year risk for hip fracture was 0.86 ± 1.78 (CI .56-1.16) compared to 1.12 ± 1.97 (CI .79-1.45, P = .26). The mean conformity for meeting the interventional threshold by either risk score was 94.8%. Conclusion. The comparison between the FRAX databases demonstrates a similarity in the absolute risk of major osteoporotic fracture. Differences are noted in the absolute number of hip fracture subjects at risk, but there is a high rate of conformity.